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In early November 2008 a woman in her 30s who lives alone in London decided that she wanted to die. She was depressed. She felt that she only suffered and caused suffering to others, and that she did not deserve to live. Yet from the outside her life seemed fulfilling and successful. A graduate building a career as a writer, she was still going about her daily affairs pretty much as normal, but she was unable to be happy and she could see no way out of her predicament. She was not sleeping well and had lost interest in food.

She investigated ways to die. The internet provided her with detailed instructions on how to kill herself using a plastic bag filled with helium which is reported (by advocates) to deliver a painless and certain death. On Friday 21 November she ordered a large disposable helium cylinder from an online retailer.

The cylinder cost £25 with £6 delivery in three days or £20 for next-day delivery. She wanted the next-day delivery, but there was not enough money on her pre-pay card so it was ordered for Monday 24 instead.

On Saturday 22 November she followed the instructions and made the bag using household objects.

On Sunday 23 November a friend phoned. They chatted (she could cover up her sadness for a while) and when they said goodbye she realised that that conversation would be their last and regretted this. This was the first doubt about dying she had had for many weeks.

Next morning, the day she had decided to die, she was full of conflict and ambivalence. Life was not worth it, but never seeing her friends or her family again was not desirable either. She had thought about it for much of the night in her own silent agony. The early morning sounds of the street outside gave her a nudge, and she walked the short distance to her local accident and emergency department for help. She was seen by the psychiatric team there and was able to tell her whole story to a friendly and patient psychiatric nurse. She felt a little better.

Later in the day she was taken home by one of the team of nurses who would care for her there as part of the home treatment service. On the doorstep was the helium cylinder. It had been delivered at 9am, an hour after she had left for the hospital. The woman would not touch it and asked the nurse to take it away. The next day I saw her, and while I was there I asked about the bag. She gave it to me, relieved to have it out of her home.

A week later I asked her how she felt about these events. She told me she was still shocked by it all, but was getting back to her writing, was seeing friends a little, exercising, and working out what she wanted to do with her life, which she was now glad to have. She told me that it was scary how close she came to dying, that her death had seemed so inevitable then. She was happy that the combination of factors which kept her alive that weekend had come together as they did. She listed them – not having enough money for the overnight delivery of the cylinder, her friend phoning, the cylinder not being delivered until she had already left for the hospital. “I’m lucky to be alive.” she said.

When I heard the director of EXIT International, Philip Nitschke, talk in October, (something I blogged about at the time), I learned that the instructions placed on the internet by organisations such as his are primarily intended to help terminally ill people prepare to commit suicide.

People with suicidal feelings are nearly always deeply ambivalent, and their commitment to the act often fluctuates. This is as true for terminally ill people as it is for other groups. Public health measures to reduce suicides largely concentrate on reducing access to the means of suicide, the opposite strategy to that advocated by EXIT International. I was worried that these instructions would be used to tragic effect by someone at whom they were not aimed. I am glad that on this occasion I am writing about a patient who is still alive.

William Lee is an MRC Research Training Fellow at the Institute of Psychiatry and a Specialist Registrar in Adult and Old Age Psychiatry in London.

Competing Interests: The author has experience of working in palliative care. The author has no religious affiliation.

Thank you for this very timely entry. It is well known from the American experience that availability and easy access to handguns means an increased number of violent deaths (and suicides). The same presumably applies to other means of self destruction. Unfortunately the BMJ has recently chosen to publish the case of a COPD patient submitted to medical euthanasia in the Netherlands. When mainstream medicine sends out such signals to patients and the general public, it is no wonder that demand for such “services” grows. We should be more firm in our belief in life and overall support for depressed or terminally ill people, rather than leading them to the exit.

EB

This surely is a very interesting article. In the presented case, all worked out for the best. Undoubtedly, in patients with depression, far other means than internet-provided suicide instructions are necessary and desirable. However, in terminally ill as well as old, multimorbid patients, the situation seems to be a diffent one to me. Modern medicine occasionally prolongs lives beyond reasonable boundries.

As the demographic structure of our society reveals, the question of euthanasia is one that will undoubtedly be increasingly discussed in future. It remains a personal choice of each individual. Depriving the public of facts about this topic will not make the questions in the heads of the concerned evaporate. An open discussion is the way we need to go and I thank the BMJ for reporting on respective cases in the past.
I do not agree with Dr Papagiannis who states that euthanasia is not consistent with a “firm belief in life”. I believe that in specific cases, it is a way to end your own life in dignity.

Alex

Nitrogen is cheaper and that’s how I intend to go if I am ever terminally ill. I don’t want my last words to be all high pitched a squeaky.

Matiram Pun

Thank you Dr Lee,

This is great article indeed. The access to the information and service for such acts will definitely lead to many other (?) premature suicide among others than intended (terminally ill).

I think access to such information should be restricted only to those terminally ill or the people who fall in that category.

Best wishes,
mati

Dr Mike Launer

I was attracted to this article by the title. I regularly hear the phrase ‘lucky to be alive’ from PTSD patients with minimal physical injury, usually, just whiplash from a road traffic acident. The phrase is usually put in their mind by an overzealous ambulance or A&E staff member who passes an off the cuff remark about the patient being just two cm from death. In my experience this guarantees PTSD. Maybe we need a national anti-PTSD campaign.

Ian Barley

As a “failed suicide” from my twenties I was interested in this article. I believe that access to means is the determining factor in the rate of success of different groups of suicides. But I’m not an expert and am ambivalent about any blanket measures that make suicide a more clumsy outcome for the terminally ill who chose that course of action.
What did impress me was that the descriptive passages in para 1 & 6 are the most effective and clear description of my experience of suicidal depression that I have ever found, anywhere.

Dave Bush

To put the same facts in a different perspective – it is entirely likely that precisely because assisted suicide is illegal this poor woman had to plan to do it alone and in secret.

If assisted suicide was legal, she could have sought appropriate counseling, safe in the knowledge that if it failed to change her plans, she would then receive assistance in with her plans.

Cosmo

Your story of meeting a nice psychiatric nurse just sounds too glib to be true. Mental health help is virtually non existent, and as for someone going to her home to help long term, well,plain rubbish. I speak from experience. And I agree with Mr Bush, although his blog is old, his theory is right. If assisted suicide were legal there would have had to have been professional interference. Medical services have been unable to alter my depression, or painkillers my pain.(I use 5 types including morphine).My genetic disease will be terminal in a few years but because there is no assisted suicide which I could opt for much later, I have had to start making plans already so that things are ready before I can no longer help myself. I do not want my family to go to jail for me.Things have not improved, and there has still been too little debate.